Rapid Responses to:

EDITORIALS: John O’Brien Antipsychotics for people with dementia BMJ 2008; 337: a602 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

it's all about the patient

Paddy Quail   (10 July 2008)

Antipsychotic prescribing in care homes is a marker of system failure.

Clive E Bowman   (10 July 2008)

it's all about the patient 10 July 2008
Paddy Quail, Medical Director Intercare Holy Cross Centre, Calgary , Alberta T2S 3C3 Send response to journal: Re: it's all about the patient	The blunt treatment of so-called behavioural and psychological symptoms of dementia with anti-psychotics is a metaphor for medical care of the older patient. Individualized care plans with a true patient focus in a supportive environment will filter many prescriptions. The problem very often isn't the patient but the provider and the care setting. Our residential prevalence has fallen from 36% to 20% in 18 months thanks to a concerted team approach to challenging behaviours. Competing interests: None declared
Antipsychotic prescribing in care homes is a marker of system failure. 10 July 2008
Clive E Bowman, Medical Director BUPA Care Services BUPA Care Services, Bridge House, Outwood Lane, Horsforth, Leeds LS18 4UP Send response to journal: Re: Antipsychotic prescribing in care homes is a marker of system failure.	The editorial by John O’Brien regarding the use of Antipsychotics (1) provides a welcome contribution to the use and abuse of these prescribed drugs generally and specifically with respect to patients resident in care homes. With regard to antipsyhcotic use in care homes, there can be no doubting the seriousness and often highly charged concern expressed by the public, press and politicians (2) alike. The problem is a lack of understanding of the needs of care home residents and inadequate development of systems for the healthcare support of the care home population generally. The most visible indicator currently of this inadequacy is the prescribing and use of antipsychotic agents. There are now some three care home beds for every "NHS" establishment bed (all specialties) in England, a significant proportion of these provide refuge and care for people with mental impairment, usually related to a dementia. Commonly, people are transferred to care homes following a crisis and acute hospital admission and our experience is that some 40% of antipsychotic prescriptions to care home residents have been initiated in NHS hospitals. The transfer of medical care to receiving General Practitioners (who typically are not the patient’s usual or previous GP) is seldom supported by adequate information to encourage a programme of gradual drug withdrawal. Care homes may become overwhelmed by the challenge of people with dementia, individually or collectively. Whilst some of these homes will be lacking skills, leadership or commitment, often the severe behavioural disturbances cannot be addressed simply through more and improved training within the levels of staffing funded to provide care for what can be extreme needs. It remains the case, in these circumstances, that a visiting doctor has to provide some form of rapid control and antipsychotics have an established role, albeit not one that is well evidenced. These circumstances are not dissimilar to those that lead to antispsychotic prescription in hospitals when behaviours pose unacceptable risk to the individual or those around them. The real problem is that what might be justifiable as an emergency treatment becomes unacceptably embedded as routine. Care home residents and the NHS rely heavily on General Practitioners to provide medical care and support but this is almost certainly provides and inadequate medical supervision and expertise to meet the complexity and intensity of needs, reflected in prescribing, where the purpose and efficacy of treatment of care homes residents is often unclear. In addition to antipsychotics drugs, what is the expected benefit of lipid-lowering agents in this population, whose well being is probably dependent upon adequate nutrition than control of lipid levels? The observation of supplemental feeding in frail patients prescribed statins does seem ridiculous. Similarly, the often large doses of diuretics observed having little or no effect on gravitational oedema, may contribute significantly to dehydration and its consequences including falls and fractures - another matter of health and public concern. Finally, whilst hospitals typically have actively managed antibiotic policies as part of their infection control strategies, such approaches are largely absent in the community and this means that there is little or often no prescribing support or monitoring for antibiotics in care homes. This range of problems underlines the need for a systematic approach to the healthcare needs of care home residents. The time for watchful waiting and dutiful reporting must now be replaced by committed action. Yours sincerely Clive Bowman 1 John O'Brien Antipsychotics for people with dementia Published 9 July 2008, BMJ 2008;337:a602 2 All-party Parlimentary Group on Dementia, Always a last resort: Inquiry into the prescription of antipsychotic drugs to people with dementia living in care homes April 2008 http://www.alzheimers.org.uk/downloads/ALZ_Society_APPG.pdf Competing interests: Medical Director Bupa Care Services (over 400 Care Homes UK, Spain, NZ and Australia)